NUR 621 Healthcare Reimbursement Training 

Grand Canyon University NUR 621 Healthcare Reimbursement Training  – Step-By-Step Guide

This guide will demonstrate how to complete the Grand Canyon University NUR 621 Healthcare Reimbursement Training assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NUR 621 Healthcare Reimbursement Training                  

Whether one passes or fails an academic assignment such as the Grand Canyon University NUR 621 Healthcare Reimbursement Training depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NUR 621 Healthcare Reimbursement Training                  

The introduction for the Grand Canyon University NUR 621 Healthcare Reimbursement Training is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NUR 621 Healthcare Reimbursement Training                  

After the introduction, move into the main part of the NUR 621 Healthcare Reimbursement Training assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NUR 621 Healthcare Reimbursement Training                  

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NUR 621 Healthcare Reimbursement Training                  

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NUR 621 Healthcare Reimbursement Training 

The purpose of this training, which focuses on healthcare reimbursement, is to introduce new nurses to healthcare insurance, the reimbursement process, and how insurance companies finance healthcare services. This will help staff members develop the better work habits and attitudes that are required for higher levels of productivity. The specific learning goals for this training are to: Assist new employees and other organization stakeholders in learning and identifying the different types of health insurance, such as Medicare, Medicaid, and private insurance, and how each of the health insurance reimburses money to the healthcare organizations. To comprehend the role of healthcare insurance in the provision of healthcare services.

What is healthcare reimbursement?

Healthcare reimbursement can be defined as the money received by a hospital, diagnostic center, or other healthcare institution for providing a medical service. The most typical form of reimbursement is fee-for-service (FFS) (Selden, 2020). The cost of a patient’s medical treatment is often partially or completely covered by health insurance or a government payer. Usually, a patient is also accountable for some of the expenses. Patients without health insurance are responsible for paying the whole cost of their treatment to the hospital or other healthcare institution (Marta et al., 2021). Usually, these services are paid for after they are received. The patient or the insurance provider, whoever is responsible for paying the medical expenses, will get a bill from the provider.

Why is healthcare reimbursement necessary?

The significance of healthcare reimbursement lies in its role of guaranteeing remuneration for healthcare providers in exchange for the services they render, thereby enabling them to sustain the provision of healthcare services (Haglin et al., 2020). Selecting an insurance plan that provides adequate coverage for healthcare expenses is a crucial aspect of healthcare reimbursement for patients, as it serves to reduce the financial burden imposed on patients in terms of reimbursing healthcare costs (Malmivaara, 2020).

How Medicare Reimburse Healthcare Organizations

Medicare offers insurance coverage to a substantial number of individuals in the United States who are either aged 65 and above or those under 65 with specific enduring disabilities (Haglin et al., 2020). Medicare beneficiaries have the option to seek medical services at a diverse range of facilities, with hospitals being frequently utilized for emergency treatment, inpatient procedures, and extended hospitalization periods. Medicare benefits frequently encompass care provided at such facilities under the purview of Medicare Part A, with the reimbursement for these services from Medicare exhibiting variability. The process of billing is determined by the provider’s affiliation with Medicare and the mean expense associated with the provision of care for a particular diagnosis or procedure.

The Medicaid reimbursement systems exhibit variations across different states, although certain similarities can be identified. The most prevalent method of reimbursement in healthcare is fee-for-service (FFS) (Dehnavi et al., 2021). Under the Fee-For-Service (FFS) model, providers are remunerated with a predetermined payment in return for the services they render. Fee-for-service (FFS) rates are designed to remunerate medical practitioners exclusively for the healthcare services rendered to an individual. As a result, medical practitioners do not derive advantages from this commercial transaction as they interact with individuals who possess private health coverage.

How Private Insurance Reimburse Healthcare Organizations

Private insurance companies engage in individual negotiations with healthcare providers and hospitals to establish mutually agreed-upon reimbursement rates. Certain healthcare facilities and healthcare providers may decline to admit patients if their insurance coverage does not offer sufficient reimbursement unless the situation qualifies as an emergency (Haglin et al., 2020). The conventional procedure entails the consumer’s payment of an initial premium to a health insurance company, thereby enabling the individual to collectively distribute the “risk” with numerous other enrollees who are making comparable payments (Czech et al., 2020).

Differences Between Cost, Charge, and Payment

For individuals seeking medical treatment, the cost typically denotes the financial obligation they are required to personally cover for healthcare services. The cost of delivering a service varies significantly from the amount incurred by providers, such as healthcare organizations or clinicians (Haglin et al., 2020). Moreover, the issue becomes more intricate as the cost to the healthcare provider is frequently determined by incorporating expenses from various categories such as personnel and equipment, which may appear unrelated to the care provided to an individual patient (Himmelstein et al., 2020).

Differences Between Cost, Charge, and Payment

The clarity of the relationship between price fluctuations and costs-per-service calculation could be enhanced by categorizing costs into specific components, such as “patient check-in” and “collecting medical history”. While it is technically feasible, conducting such an analysis would be labor-intensive (Haglin et al., 2020). It would involve meticulously observing and quantifying the amount of time spent on each task for a given episode, referred to as “labor input.” Additionally, it would necessitate accounting for expenses related to space, non-consumable equipment, and administrative overhead on a minute-by-minute basis. A limited number of provider organizations demonstrate a willingness to invest such a level of effort.

Payment is a remittance issued by a party other than the recipient to compensate a service provider for rendered services (Abràmoff et al., 2022). There are various methods by which healthcare services can be financially compensated. These include a fee-for-service model, where a specific amount is charged for each service rendered, a per diem model, where a fixed daily rate is charged for hospital stays, a diagnosis-related groups (DRGs) model, where a predetermined amount is charged for each episode of hospitalization based on the diagnosis, and a capitation model, where a fixed amount is charged for each patient under the provider’s care.

Diagnostic Related Groups (DRGs)

Diagnostic Related Groups (DRGs) are employed as a means of categorizing patients who share comparable clinical conditions and treatment requirements. An instance can be observed in which a patient who has undergone a surgical procedure for a knee replacement would be classified within the Diagnosis-Related Group (DRG) 469 (Haglin et al., 2020). This particular DRG pertains to major joint replacement or reattachment of the lower extremity, specifically when accompanied by a Major Complication or Comorbidity (MCC). The determination of this Diagnosis-Related Group (DRG) incorporates an assessment of the patient’s medical condition, the intricacy of the procedure, and any potential complications or comorbidities that could impact the provision of healthcare to the patient.

Based on the patient’s diagnosis and the services given while they were a patient in the hospital, Medicare uses DRG to pay hospitals for inpatient stays (Bredenkamp et al., 2020). As a result, hospitals get a set payment for each patient depending on the DRG that was given to them. DRGs first appeared in the Medicare Prospective Payment System (PPS)  in 1982 (Abràmoff et al., 2022). The new system was designed to take the place of the old one, which reimbursed providers based on the real costs of delivering treatment. To assist decide the reimbursement a hospital will get for providing treatment to a patient, DRGs are a means to divide hospital inpatient cases into groups that are anticipated to have comparable expenses.

DRGs come in a variety of forms and are used in several contexts. One form is the Major Diagnostic Category (MDC) DRG, which, for financial reasons, compiles patients with comparable diagnoses and therapies (Abràmoff et al., 2022). The Surgical DRG is an additional kind that is used to classify patients according to the surgical treatments they undergo. Other DRGs include Transfer DRGs, which are used when a patient is moved to another hospital, and Pediatric DRGs, which are used for children. Some DRGs, like those for HIV/AIDS or mental health, are tailored specifically to those disorders. Healthcare practitioners and billing specialists must comprehend the various DRG classes to correctly classify and charge for services.

How Insurance Reimbursement Affects Private Pay Patients

Individuals lacking health insurance tend to incur lower out-of-pocket expenses for healthcare compared to those who possess health insurance, primarily due to their reduced utilization of services that are both less frequent and less expensive (Selden, 2020). Uninsured households bear a greater burden of their overall healthcare expenses through direct payments compared to insured households. Moreover, uninsured households are more prone to experiencing significant medical costs in their income levels. Adults without health insurance are at a decreased likelihood compared to adults with any form of health coverage to obtain preventive and screening services, as well as experiencing delays in receiving these services. 

Summary

The healthcare reimbursement systems in the United States encompass a combination of public and private third-party coverage (Dehnavi et al., 2021). These systems involve contributions from employers, individuals, and the government to cover the expenses associated with healthcare. Individuals and employers remunerate private insurance companies with premiums to defray healthcare expenses. Government coverage is available to specific populations at both the federal level, through programs such as Medicare, the Department of Defense, and the Bureau of Indian Affairs, and at the state level, through programs like Medicaid. Typically, these sub-populations encompass individuals who are classified as elderly (aged 65 and above), low-income, disabled, and veterans, among other categories. Private insurers have the potential to offer healthcare coverage to individuals who are beneficiaries of government insurance programs such as Medicare or Medicaid.

References

•Abràmoff, M. D., Roehrenbeck, C., Trujillo, S., Goldstein, J., Graves, A. S., Repka, M. X., & Silva III, E. “Zeke”. (2022). A reimbursement framework for artificial intelligence in healthcare. Npj Digital Medicine, 5(1). https://doi.org/10.1038/s41746-022-00621-w

•Bredenkamp, C., Bales, S., & Kristiina Kahur. (2020). Transition to diagnosis-related group (DRG) payments for health : lessons from case studies. World Bank Group.

•Czech, M., Baran-Kooiker, A., Atikeler, K., Demirtshyan, M., Gaitova, K., Holownia-Voloskova, M., Turcu-Stiolica, A., Kooiker, C., Piniazhko, O., Konstandyan, N., Zalis’ka, O., & Sykut-Cegielska, J. (2020). A Review of Rare Disease Policies and Orphan Drug Reimbursement Systems in 12 Eurasian Countries. Frontiers in Public Health, 7. https://doi.org/10.3389/fpubh.2019.00416

•Dehnavi, Z., Ayatollahi, H., Hemmat, M., & Abbasi, R. (2021). Upcoding Medicare: Is Healthcare Fraud And Abuse Increasing? Perspectives in Health Information Management, 18(4), 1f. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

•Haglin, J. M., Eltorai, A. E. M., Richter, K. R., Jogerst, K., & Daniels, A. H. (2020). Medicare Reimbursement for General Surgery Procedures. Annals of Surgery, 271(1), 17–22. https://doi.org/10.1097/sla.0000000000003289

•Haglin, J. M., Richter, K. R., & Patel, N. P. (2020). Trends in Medicare reimbursement for neurosurgical procedures: 2000 to 2018. Journal of Neurosurgery, 132(2), 649–655. https://doi.org/10.3171/2018.8.jns181949

•Himmelstein, D. U., Campbell, T., & Woolhandler, S. (2020). Health Care Administrative Costs in the United States and Canada, 2017. Annals of Internal Medicine, 172(2), 134. https://doi.org/10.7326/m19-2818

•Malmivaara, A. (2020). Vision and strategy for healthcare: Competence is a necessity. Journal of Rehabilitation Medicine, 52(5), 0. https://doi.org/10.2340/16501977-2684

•Marta, G. N., Ramiah, D., Kaidar-Person, O., Kirby, A., Coles, C., Jagsi, R., Hijal, T., Sancho, G., Zissiadis, Y., Pignol, J.-P. ., Ho, A. Y., Cheng, S. H.-C. ., Offersen, B. V., Meattini, I., & Poortmans, P. (2021). The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report. Clinical Oncology, 33(5), 322–330. https://doi.org/10.1016/j.clon.2020.12.008

•Selden, T. M. (2020). Differences Between Public And Private Hospital Payment Rates Narrowed, 2012–16. Health Affairs, 39(1), 94–99. https://doi.org/10.1377/hlthaff.2019.00415

Sample Answer 2 for NUR 621 Healthcare Reimbursement Training 

Introduction

Healthcare reimbursements involved paying hospitals, diagnostic facility, health providers and other healthcare organization for the services they have offered, especially the medical services offered to clients (Chen et al.,2020). Over the years, healthcare reimbursement in USA has evolved, and today, several reimbursement models exist. In some cases, the payer cover all the costs for the care services offered to patients while in other cases, patients are required to cover for part of the services offered. In addition, in cases where a patient lacks a health insurance, then they are usually required to cover all the costs. This presentation will focus on healthcare reimbursement.

Medicare Reimbursement

Medicare reimbursement is one of the models which have been used in the USA. It is usually for people of 65 years and above. However, it can also be used in covering specific cases for people below that age, for instance with disabilities. The program has fur main parts, parts A, B, C and D. part A is also known as hospital insurance while part B is known as medical insurance (DeCherrie et al.,2021). Part A helps in covering different services such as inpatient hospital care, skilled nursing facilities, hospice care and home health services. Comparatively, part B covers outpatient services, physician services and durable medical equipment. Part C is also known as Medicare advantage and is offered by private insurance companies approved by Medicare.  The Part D covers prescription drugs through private insurance plans.

The parts of the Medicare direct the reimbursement process. For part A, the healthcare organizations which offer the services get reimburses through a prospective payment system. The system involves reception of a fixed amount of specific services given without taking into account the actual costs. Comparatively, the fee-for-service is used in  the Medicare part B. This approach entails fee schedule setting which then means that the healthcare entities get paid based on the services which they have given as guided by deductibles and coinsurance (Sen & Deokor, 2021). Part C is based on capitated payments, implying that the government pays an amount to the private insurance on behalf of a beneficiary. Part D entails combining the beneficiary premiums and government subsidies where the government subsidizes the drug costs.

Medicaid Reimbursement

Apart from the Medicare reimbursement, Medicaid has also been used. Medicaid reimbursement refers to a joint federal and stated program which offers health insurance to people from  low income families or individuals  with economically disadvantaged backgrounds and low incomes. While Medicare is straightforward and easy to understand, the Medicaid has for decades described as complex (Mitchell et al.,2023). This reimbursement is not uniform, but may vary from one state to the next.  The federal government is responsible for setting rules which need to be followed by various states, none the less, states can come with eligibility criteria, benefits and rates. Medicaid reimbursement model covers different services such as hospital care, physician services, prescription medication, long-term care and mental health services.

Medicaid reimbursement uses different reimbursement strategies. Among the approaches is Free-for-Services which involves the healthcare providers billing Medicaid for each of the services they give, and the rates involved differ from one state to the next, however, the rates are lower that payments made by private insurers.  Medicaid also uses managed care. Managed care is based on a fixed monthly payment per individual. The state negotiated contracts with the managed care organizations to determine the reimbursement rates (Lin et al.,2020).  Another strategy is the intergovernmental transfer and upper payment limit which involve funds transfer between state and local governments. Upper payment limits entails a cap on the amount of money which states can claim. Disproportionate share hospital payment are used to offset uncompensated care costs.

Private Insurance Reimbursement

Apart from the Medicaid and Medicare, there is also private insurance reimbursement models which entail private insurance companies. The companies pay the healthcare providers on behalf of their members for the services they receive. The private insurance can  take the form of employer-sponsored group, individual or family plans.  Just like in Medicare and Medicare, private insurance also uses approaches such as Free-for-Services which involves billing the insurance entities for the services offered (Xu et al.,2020). It also uses the capitation model where the providers get a fixed monthly payment for the patients regardless of the services offered to the patients.

Cost, Charge and Payment

The reimbursement for services offered by various healthcare entities require that the player involve understand payment, charge and cost. All these three terms are vital in the reimbursement process, and even though they are usually used together, they are different from each other.  Cost refers to the actual expense that a healthcare provider incurs in giving health and medical services to patients (Mitchell et al.,2023). They may be inform of overhead costs, costs used for facilities and supplies and costs incurred in purchasing equipment. It is also worth noting that costs can either be variable or fixed.  The information offered by cost aspects can be used by the providers when carrying out different activities such as allocation of resources, pricing and in exploring the sustainability options.

Charge is another term used in healthcare reimbursement.  Charge refers to the amount which a healthcare provider bills a patient or an insurance company upon provision of healthcare services. Charges are dictated by nature of services which have been offered, which may also differ from one organization to another. Charge is also heavily impacted by a hospital’s pricing policy and pricing strategy, and in some cases, the facility’s geographical location (Mitchell et al.,2023). In most cases, the charges are non-negotiable and the responsible payer is expected to pay it as it is. It also comes after healthcare providers or organizations have offered the services required by patients or a patient.

Payment is different from charge and costs. In the context of healthcare reimbursement, payment refers to the actual amount of money given to a healthcare provider. This money can either be given by an insurance company or a patient. The payment can vary in different situations. For example, the payments made by an individual or an insurance company can either be lower, equal to or more than the charges billed (Sen & Deokar, 2021). . Another factor which may impact or influence payment is the environment, for example, getting services out of the network providers, which may mean that the patient has to cover a bigger percentage of the total costs. Payment may also be influenced by the patient agreements such as copayments, deductibles and coinsurance. Negotiations can also change the amount of payments, with negotiations usually leading to lower payments.

Diagnostic Related Groups

Diagnostic related group is the classification system used to categorize and reimburse inpatient services provided by healthcare entities. The reimbursement is dictated by different factors such as the age of the patient, the kind of procedure performed, and the nature of the diagnosis. The classifications is usually to standardize payment of services given (Maryati et al.,2021).  Therefore, the focus is to ensure that there is fair and consistent reimbursements. The diagnostic related groups function through the classification of the inpatient hospital admissions into different groups, where the groups are assigned particular codes aligning to specific payment rates.  The implication is that healthcare entities get predetermined payment for each patient based on the assigned diagnostic related groups without taking into account the actual costs used when offering the patient services.

Examples of Diagnostic Related Groups

This section focuses on example diagnostic related groups. One of the examples is the DRG 292 (heart failure and shock with major complications or comorbidities. It entails patients with severe heart failure or shock conditions accompanied by major comorbidities or complications and requiring intensive medical management. The other example is DRG 177 ( Respiratory infections and inflammations with major complications or comorbidities. It is for patient with severe respiratory infections or inflammations like severe pneumonia or bronchitis, with a major comorbidity or complications

Insurance Reimbursement and Private Pay Patients

Health insurance entities, whether private or public play a  significant role in the payment of healthcare services offered to patients by different organizations. However, there are individuals who do not have health insurance from private or public entities, implying that, in case they get  treatment services from healthcare providers, then they have to pay for the services from their pocket. Insurance reimbursement impact private pay patients in various ways (Mariotto et al.,2020). One of the impacts is in the form of direct costs. Such individuals may need to pay higher out of pocket charges due to the higher costs negotiated by the insurance companies. The implication is that the healthcare providers have to bill them directly to pay the full amounts, which lead to higher out of pocket payments. They may also have reduced access to care since providers may prefer those with medical insurance covers.

References

Chen, H. C., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: how patient satisfaction in HCAHPS reflects lower readmission. International Journal of Health Care Quality Assurance, 33(4/5), 333-344. https://doi.org/10.1108/IJHCQA-03-2019-0066

DeCherrie, L. V., Wardlow, L., Ornstein, K. A., Crowley, C., Lubetsky, S., Stuck, A. R., & Siu, A. L. (2021). Hospital at home services: an inventory of fee‐for‐service payments to inform Medicare reimbursement. Journal of the American Geriatrics Society, 69(7), 1982-1992. https://doi.org/10.1111/jgs.17140

Lin, J. C., Kavousi, Y., Sullivan, B., & Stevens, C. (2020). Analysis of outpatient telemedicine reimbursement in an integrated healthcare system. Annals of Vascular Surgery, 65, 100-106. https://doi.org/10.1016/j.avsg.2019.10.069

Mariotto, A. B., Enewold, L., Zhao, J., Zeruto, C. A., & Yabroff, K. R. (2020). Medical care costs associated with cancer survivorship in the United States. Cancer Epidemiology, Biomarkers & Prevention, 29(7), 1304-1312. https://doi.org/10.1158/1055-9965.EPI-19-1534

Maryati, W., Yuliani, N., Susanto, A., Wannay, A. O., & Justika, A. I. (2021). Reduced hospital revenue due to error code diagnosis in the implementation of INA-CBGs. Int. J. Public Health Sci.(IJPHS), 10, 354. DOI: 10.11591/ijphs.v10i2.20690

Mitchell, A., Baumrucker, E. P., Colello, K. J., Napili, A., Binder, C., & Braun, S. K. (2023). Medicaid: An Overview. Congressional Research Service (CRS) Reports and Issue Briefs, NA-NA.

Sen, S., & Deokar, A. V. (2021). Discovering healthcare provider behavior patterns through the lens of Medicare excess charge. BMC Health Services Research, 21, 1-18. Doi: 10.1186/s12913-020-05876-1

Xu, H., & Intrator, O. (2020). Medicaid long-term care policies and rates of nursing home successful discharge to community. Journal of the American Medical Directors Association, 21(2), 248-253. https://doi.org/10.1016/j.jamda.2019.01.153